Trigger – part one
I am a 45 year old female, coming to you because I am having pain on the right side of my face
since the past two months
Part two – HPI
This is a 45 years old female from Debre Tabor, presented with pain on the right side of her face.
The pain is sudden, staying for a brief period of time, coming several times within a day and it is
sever, sharp pain which sometimes makes her feel like she is being teased by electric on her face.
Her pain seems to come whenever she is eating and washing her face, thus now she afraid to eat.
She has lost about 10Kg of weight in the past month from not wanting to eat for fear of the pain.
Initially she thought her pain must be related to a tooth-ache and she went to a dentist, who told
her that she has no problem and send her home with just Paracetamole. Even though she was
taking the paracetamole as her dentist told, the pain persisted thus she went back to the dentist,
who gave her paracetamole again and told her she will be fine.
Now the pain is affecting her work and her social life and she came to your OPD seeking your
help.
She has no history of visual changes, sleep difficulties
She has no history of tooth extraction or toothache
She has no history of trauma her head or face
She has no history of ear discharge or earache
She has no history of headache or family history of headache
She has no history of blurring of vision
She has no history of hoarseness of voice
She has no family history of DM/HTN
She was screened for RVI and told to be negative
He denies constipation, diarrhea, or urinary complaints.
He has no bleeding difficulties, heat/cold intolerance, or mood difficulties.
There is no personal and family history of asthma, headaches or other neurological
problems.
Part three – P/E
• General appearance
• Acutely sick looking (in Pain)
• V/S
• PR – 88 beats per minute, regular and full in volume
• RR – 24 breath per minutes,
• T – 36.5oC, axillary, in the morning
• BP – 120/70 mmHg, left arm, sitting position
• Weight – 50Kg
• Height – 1.65Cm
• BMI – 18.5 Kg/M2
• HEENT
• Pink conjunctiva, Non icteric sclera
• No dental caries
• LGS
• No LAP
• Thyroid not palpable
• No breast mass or tenderness
• Respiratory system
• Inspection
• No cyanosis or clubbing
• Symmetrically moving chest
• No use of accessory muscle
• Palpation
• Symmetrically tactile fremitus
• Symmetrical chest expansion
• Percussion
• Resonant chest
• Diaphragmatic excursion – 2 cm
• Auscultation
• Clear vesicular breath sound heard all over the chest
• No added or transmitted sounds
• CVS
• Vein – JVP 3cm above sternal angle
• Artery – all accessible peripheral arteries are palpable, regular and full volume
• Precordium
• Inspection - Quit precordium and not bulged
• Apical impulse – 4cm lateral to mid sternum at 5th intercostal
space
• Palpation
• Point of maximal impulse on same spot with apical impulse
and it is tapping
• No heave or trill
• Percussion
• The most inferior and lateral dullness of the precordium
coincideds with apical impulse.
• Auscultation
• S1 and S2
• No murmur or gallop
• Abdomen
• Inspection
• Full abdomen and Moves with respiration
• Inverted umbilicus with circular slit
• Auscultation
• Bowel sound – 14/minute
• Palpation
• Superficial palpation
• No tenderness
• No grading/rigidity
• Deep palpation
• No deep tenderness
• No mass or Organomegally
• Percussion
• Tympanic abdomen
• No fluid trill or shifting dullness
• GUT
• No supra-pubic tenderness
• No costo-vertebral angle tenderness
• Musculoskeletal
• No bone or joint tenderness
• No edema
• Integumentary system
• No rash
• No palmar or plantar pallor
• CNS
• GCS – 15/15
• Oriented to time, person and place
• Cranial nerve examination
• Olifactory nerve – can smell bilaterally
• Optic nerve
• Fundoscopy – normal looking fundus and macula
• Test Visual Acuity
• 20/20 on snellens chart
• Test for color vision
• Intact color vision ischihara
• Test for Visual Fields by Confrontation
• Normal visual field
• Test Pupillary Reactions to Light
• Billaretally reacyve pupils for both direct and consensual tests
• Occulomotor, Trochlear & Abducent nerves
• Cam move the eyes in all range of motion
• Trigeminal
• Motor examination
• Tenderness was elicited upon palpation of the right side
masseter muscle otherwise intact contraction of the muscles of
mastication.
• Sensation of the face
• Corneal reflex is intact
• Intact in all the three divisions of trigeminal nerve
• Facial nerve
• No facial deviation, can smile & can frown
• Can fell sweet and salty test
• Vestibulochochlear test
• Can hear finger rub bilaterally
• Vagus & Glossopharyngeal
• Can swallow
• Centrally located uvula
• Accessory
• Can shrug
• Can turn head against resistance
• Hypoglossal
• No tongue deviation
Motor - grossly intact
Sensory system – grossly intact
Ix – part four
• CBC
Test result Normal value
WBC 10.2 x 103 4 – 11.5 x 103
Granulocte 60% 25–60%
Monocyte 40% 25 – 50%
HGB 13.5 M 12.9 – 15.5
F 11.8 – 14.8
HCT 40.5% M - 38.8–46.4
F - 35.4–44.4
MCV 90fl 80 – 100fl
MCHC 40fl 33 – 64fl
PLT 150 x 103 150 – 400 x 103
Serum electrolyte
K+ - 3.6Meq/dl Normal value -3.5 -5.5mequ/dl
Na+ - 137mequ/dl Normal value – 135 – 145meq/dl
Ca++ - 9.1meq/dl Normal value – 8.7 – 10.2mg/dl
Renal function test
Cr – 2.8 mg/dl Normal value <1.1mg/dl
BUN – 48mg/dl Normal value - <20
Fasting blood sugar – 108mg/dl
PITC – Non reactive
Lipid profile
Total cholestrol – 210mg/dl Normal value – 200 to 239
Triancyglycerole – 100mg/dl Normal value <150 mg/dL
LDL – 120mg/dl Normal value 100 to 129
HDL – 65mg/dl Normal value ≥60
MRI of the skull and the brain
Normal size and configuration of the ventricles
No midline shift
Normal appearing brain paranchyma
Normal appearring skull
Electrophysiologic test of trigeminal nerve (Nerve conduction test)
Normal nerve conduction test appears normal
